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Bargain lifesaver

HUNDREDS of thousands of babies each year could be spared from starting life
with HIV at a cost of just &dollar;4 each. That’s the startlingly hopeful
conclusion from a study conducted in Uganda.

More than 600 women with HIV took part in the trial. All were given an
antiviral drug during labour, and their babies were treated with the same drug.
Half the mothers and infants were given AZT, the other half a newer drug called
nevirapine. Both interfere with the enzyme reverse transcriptase, without which
HIV cannot replicate.

“We were hoping nevirapine would be as good as AZT, but it turned out to be
better,” says Anthony Fauci, director of the National Institute for Allergy and
Infectious Diseases (NIAID) near Washington DC, which sponsored the trial. In
sub-Saharan Africa, between 25 and 35 per cent of babies born to women with HIV
themselves become infected. In the group receiving AZT, 25.1 per cent were
infected at around 15 weeks. But in the nevirapine group, the figure was just
13.1 per cent.

Nevirapine also has the advantage that it crosses the placenta readily and
breaks down slowly, so can be given in small doses. In the Ugandan trial, the
women received a single dose of nevirapine during labour, and their babies were
given another dose within three days of birth. AZT had to be given several times
over several hours during labour, and twice a day to the infants for one
week.

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These modest doses mean that developing countries should be able to afford
nevirapine. In Europe and North America, AZT is often given to pregnant women
with HIV over a period of months, cutting the rate of transmission to less than
10 per cent. But this costs more than &dollar;800.

At just &dollar;4 per mother and child, the nevirapine treatment should be
within the reach of countries that until now have had to give up on protecting
their infants from HIV. And the NIAID is now even suggesting that the nevirapine
treatment is so cheap that it could be given routinely to women in labour in
developing countries experiencing severe HIV epidemics.

But James McIntyre, director of the perinatal HIV research unit at the Chris
Hani Baragwanath Hospital in Johannesburg, says this ignores the realities of
health care in poor countries. “Only 50 per cent of women in developing
countries deliver in a health service setting,” he says. McIntyre argues that
health infrastructures need to be improved to offer all pregnant women tests for
HIV so that they can be given the drug during labour if they are infected.

The optimism about nevirapine and mother-to-child transmission of HIV comes
hard on the heels of preliminary results suggesting that a simple drugs cocktail
could provide an affordable treatment for adults with AIDS in developing
countries (This Week, 1 May, p 4). But much work remains to be done. For
instance, about one in seven HIV-free babies born to infected mothers will
acquire the virus from breast milk. The next phase of the Ugandan study will
look at the effectiveness of nevirapine at preventing transmission during
breastfeeding.